E-B Pain Relief E-B Pain ReliefE-B Pain Relief Distribute the promotion of EBM passwordDistribute the promotion of EBM password

Life long learning with EBM Prof Eiad Al-Faris MD, MSc, MMEd, MRCGPProf Eiad Al-Faris MD, MSc, MMEd, MRCGP Consultant Family MedicineConsultant Family Medicine Prof. King Saud UniversityProf. King Saud University Supervisor -King Saud University chair for medical educationSupervisor -King Saud University chair for medical education

Outline IntroductionIntroduction Definition of EBMDefinition of EBM Steps of EBMSteps of EBM Practical searchPractical search ConclusionConclusion ClosureClosure

, ,000 ? 250,000 INFORMATION EXPLOSION MEDICAL JOURNALS 4

Rule 31 – Review the World Literature Fortnightly* 5,000? per day 1,260 per day 55 per day

Clinical Scenario Ibrahim is a 60 years old teacher, he is known case of hypertension. He presented to the ED with severe chest pain for the last two hours.Ibrahim is a 60 years old teacher, he is known case of hypertension. He presented to the ED with severe chest pain for the last two hours. In addition to hitory/ exam and ECG, you wonder should you request for the timely diagnosos: troponin or creatine kinase- MB or both?In addition to hitory/ exam and ECG, you wonder should you request for the timely diagnosos: troponin or creatine kinase- MB or both?

When confronted with a clinical question, whom usually you consult? When confronted with a clinical question, whom usually you consult?

Colleagues- experts A great source of information.A great source of information. Quick, affordable and accessible.Quick, affordable and accessible. But potentially very biased:But potentially very biased: Variability Variability Not updated Not updated

Textbooks Rapidly out-of-date (2-4y).Rapidly out-of-date (2-4y). They are a good source of background information (pathophysiology),They are a good source of background information (pathophysiology), but a poor source of information for most foreground questions (clinical).but a poor source of information for most foreground questions (clinical).

Burn your traditional textbooks

The integration of the current best evidence (from research) with our clinical expertise and patient’s values. The integration of the current best evidence (from research) with our clinical expertise and patient’s values. EBM is

Three (Es)- EBM Components

ClinicalPractice The “Evidence Transfer Gap” Controlled trials

Rules of Evidence All evidence is not created equal.All evidence is not created equal. Values always influence decisions.Values always influence decisions. Evidence alone never makes clinical decisions.Evidence alone never makes clinical decisions.

Hierarchy of Evidence Meta-analysis of RCTs Multi-centric large RCTs Single Centre RCT Observational studies patient-important outcomes Clinical experience Basic research test tube, animal, human physiology 16

Ask Acquire Appraise Apply Act & Assess Patient dilemma Principles of evidence-based practice Evidence alone does not decide – combine with other knowledge and values Hierarchy of evidence Process of EBP

5 As to practice EBM A sk focused Question(s) A cquire the Evidence(s) A ppraise the Evidence(s) A pply the best Evidence A ssess your Performance

A cquire the Evidence(s) A ppraise the evidence(s) A pply The best evidence to patient A ssess your patient A sk clinical questions 6 As to practice EBM A ssess Yourself

Assess Your Patient HistoryHistory Physical examinationPhysical examination Objective data – labs, x-raysObjective data – labs, x-rays Formulate differential diagnosis Pretest probability of disease

A cquire the Evidence(s) A ppraise the evidence(s) A pply The best evidence to patient A ssess your patient A sk clinical questions 6 As to practice EBM A ssess Yourself

To answer a clinical question effectively, First, turn your scenarios into 'well-built' clinical Q. Four domains: PICO Four domains: PICO 1) the patient (problem) 2) the intervention or exposure 3) the comparison (intervention) 4) the clinical outcomes

For healthy adults is it worthwhile to give aspirin as prophylaxis to reduce MI and or stroke ? For healthy adults is it worthwhile to give aspirin as prophylaxis to reduce MI and or stroke ?

Aspirin and Primary Prevention 1. Patient population. 2. Intervention. 3. Comparison intervention. 4. Outcomes. Asymptomatic adults with no risk factors Aspirin Placebo Incidence of CV events “In asymptomatic adults no risk factors, would the use of aspirin reduce the incidence of cardiovascular events? “In asymptomatic adults no risk factors, would the use of aspirin reduce the incidence of cardiovascular events?

Ask Clinical Questions (PICO) Patient/ Population Outcome Intervention/ Exposure Comparison Components of Clinical Questions (PICO) In patients with acute MI In post- menopausal women In women with suspected coronary disease does early treat- ment with a statin what is the accuracy of exercise ECHO does hormone replacement therapy compared to placebo compared to exercise ECG compared to no HRT decrease cardio- vascular mortality? for diagnosing significant CAD? increase the risk of breast cancer?

Types of clinical questions Therapy and harm: how to select treatments to offer patients that do more good than harmTherapy and harm: how to select treatments to offer patients that do more good than harm Diagnostic tests: how to select and interpret diagnostic tests, in order to confirm or exclude a diagnosisDiagnostic tests: how to select and interpret diagnostic tests, in order to confirm or exclude a diagnosis Prognosis: how to estimate the patient's likely clinical course over timePrognosis: how to estimate the patient's likely clinical course over time

Acquire the Best Evidence Prefiltered Sources:Prefiltered Sources: Secondary sources –ACP Journal Club ( –Cochrane Library ( software.com/cochrane) software.com/cochranewww.update- software.com/cochrane –Up-to-Date ( –Clinical Evidence ( –InfoRetriever ( –Ovid ( –MD Consult ( –Medscape ( –Dynamed ( ) Unfiltered SourcesUnfiltered Sources –MEDLINE ( ( –Google ( ( We need to focus and familiarize yourself with few of them

EBM journal / ACP j. club Clinical Practice Guidelines Cochrane Library / Systematic Reviews Computer Decision Support System (CDSS) eg. Dynamed “Point of care” Single RCT in Journal Developments (4 s) that facilitate EBM Practice

Pre-filtered Sources: –Cochrane Library –Up-to-Date –Clinical Evidence –Ovid

–ACP Journal Clubwww.acpjc.org –InfoRetriever –MD Consult –Medscape –Dynamed 31

PROCESS 120+ journals scanned120+ journals scanned –50,000 articles Is it valid? (<5%)Is it valid? (<5%) –Intervention: RCT –Prognosis: inception cohort –Etc Is it relevant?Is it relevant? –6-12 GPs & specialists asked: Relevant? Newsworthy? < 0.5% selected< 0.5% selected EBM can reduce reading need How much is valid AND relevant? Number Needed to Read is 20+ Number Needed to Read is 200+

 Deals with barriers Involves seniors and juniors Involves seniors and juniors EBM Environment EBM Environment New EBM teaching models New EBM teaching models The Challenge – Bridging the gap!

Appraise the Evidence Relevance: It focuses on medical problems common to our practice. patient-oriented evidenceRelevance: It focuses on medical problems common to our practice. patient-oriented evidence Validity: Correctness ( true)Validity: Correctness (likely to be true) Results:Results: Clinically important Can we apply the results to our patient?Can we apply the results to our patient? Applicable in and useful for my patients

Relevance Consider three questions to determine Relevance –Common to practice – Require change of practice –Patient-oriented outcome

POEM Vs. DOE POEM: Patient-oriented evidence that matter mortality, morbidity, quality of life DOE: Disease-oriented evidence pathophysiology, pharmacology, etiology

Comparing DOE and POEM DOEPOEM Antihypertens therapy Lowers Blood Pressure MortalityMICVA Screening for prostate CA PSA screening detects Prostate CA at an early stage Unknown whether PSA screening reduces Mortality

Clofibrate decreases cholesterol Clofibrate decreases CV mortality/ Morbidity It Increases overall mortality β – blockers are contraindicated for heart failure patients β – blockers are indicated for heart failure patients Antiarrhythmic A decreases PVCs Antiarrhythmic A decreases symptoms Antiarrhythmic A increases mortality 40 DOE POEM The cardiac arrhythmia suppression trial. N Engl J Med

Clofibrate decreases cholesterol Clofibrate decreases CV mortality/ Morbidity It Increases overall mortality β – blockers are contraindicated for heart failure patients β – blockers are indicated for heart failure patients Antiarrhythmic A decreases PVCs Antiarrhythmic A decreases symptoms Antiarrhythmic A increases mortality DOE POEM The cardiac arrhythmia suppression trial. N Engl J Med

Clofibrate decreases cholesterol Clofibrate decreases CV mortality/ Morbidity It Increases overall mortality β – blockers are contraindicated for heart failure patients β – blockers are indicated for heart failure patients Antiarrhythmic A decreases PVCs Antiarrhythmic A decreases symptoms Antiarrhythmic A increases mortality DOE POEM The cardiac arrhythmia suppression trial. N Engl J Med

5 journals with highest concentration of POEMS JAMA-17%JAMA-17% Annals of Internal Medicine-17%Annals of Internal Medicine-17% NEJM-16%NEJM-16% Journal of the American Board of Family Practice-16%Journal of the American Board of Family Practice-16% Journal of Family Practice-15%Journal of Family Practice-15% Ebell MH et al. J Fam Pract : Ebell MH et al. J Fam Pract :

Validity In RCT: RandomizationRandomization BlindnessBlindness Drop-outDrop-out ITTITT

Results Results clinical importance can be assessed by its: 1. Magnitude 2. Precision

50 Results of a hypothetical randomized trial Total N. of Pts No. who did not improve No. who improved Treatment Ibuprofen 40337Placebo

51 Calculations made from these results Experimental event rateExperimental event rate Control event rateControl event rate Experimental event odds Experimental event odds Control event oddsControl event odds Odds ratioOdds ratio Relative riskRelative risk Relative risk increaseRelative risk increase Absolute risk increase or reductionAbsolute risk increase or reduction NNTNNT

52 Results of a hypothetical randomized trial Total N. of Pts No. who did not improve No. who improved Treatment Ibuprofen 40337Placebo

53 Relative Risk  A relative risk is the risk in the treatment group compared to the risk in the control group.  A relative risk of (1) means there is no difference between the groups

54 Results of a hypothetical randomized trial Total N. of Pts No. who did not improve No. who improved Treatment Ibuprofen 40337Placebo

55 Results of a hypothetical randomized trial Total N. of Pts No. who did not improve No. who improved Treatment Ibuprofen 40337Placebo

Experimental event rat: 22/40 =55% Control event rate: 7/40 = 18%

Relative risk: =0.55/ 0.18= 3.1 Relative risk increase: = / 0.18 = Absolute risk increase or reduction= = 0.37 NNT = 1/ 0.37 = 2.7

58 Odds The odds of an event are the probability of it occurring compared to the probability of it not occurring

59 Results of a hypothetical randomized trial Total N. of Pts No. who did not improve No. who improved Treatment Ibuprofen 40337Placebo

60 What was the ratio of odds? The odds of an event in the treatment (or exposed) group compared to the odds in the control (or unexposed) groupThe odds of an event in the treatment (or exposed) group compared to the odds in the control (or unexposed) group OR=(A/B)/(C/D)OR=(A/B)/(C/D)

61 An odds ratio  is the odds of an event in a patient in the experimental group relative to that of a patient in the control group.  Relative risk is the risk of an event in a patient in the experimental group relative to that of a patient in the control group.

62 Results of a hypothetical randomized trial Total N. of Pts No. who did not improve No. who improved Treatment Ibuprofen 40337Placebo

E Experimental event odds: 22/18= 1.2 Control event odds: 7/ 33 =0.21 Odds ratio: 1.2/ 0.21= 5.7

Applicability 3 arms for the applicability criteria to be looked at (IPP) InterventionIntervention Patient populationPatient population Patient preferences.Patient preferences.

To answer a clinical question effectively, First, turn your scenarios into 'well-built' clinical Q. Four domains: PICO Four domains: PICO 1) the patient (problem) 2) the intervention or exposure 3) the comparison (intervention) 4) the clinical outcomes

Clinical Scenario Ibrahim is a 60 years old teacher, he is known case of hypertension. He presented to the ED with severe chest pain for the last two hours.Ibrahim is a 60 years old teacher, he is known case of hypertension. He presented to the ED with severe chest pain for the last two hours. You wonder should you request troponin or creatine kinase- MB or both?You wonder should you request troponin or creatine kinase- MB or both?

Treponine or creatine kinase-MB 1. Patient population. 2. Intervention. 3. Comparison intervention. 4. Outcomes. Patients attending the ED with chest pain Troponine creatine kinase-MB Accuracy of diagnosis of IHD “In “In Patients attending the ED with chest pain,, is troponine as compared to creatine kinase-MB more valid for the diagnosis of ischemic heart disease?

Information management Principles

OBJECTIVE: The aim of this study was to evaluate the diagnostic efficacy of multiple tests-heart-type fatty acid-binding protein (H- FABP), cardiac troponin I (cTnI), creatine kinase-MB, and myoglobin-for the early detection of acute myocardial infarction among patients who present to the emergency department with chest pain. METHODS: A total of 1128 patients provided a total of 2924 venous blood samples. Patients with chest pain were nonselected and treated according to hospital guidelines. Additional cardiac biomarkers were assayed simultaneously at serial time points using the Cardiac Array (Randox Laboratories Ltd, Crumlin, United Kingdom).METHODS: A total of 1128 patients provided a total of 2924 venous blood samples. Patients with chest pain were nonselected and treated according to hospital guidelines. Additional cardiac biomarkers were assayed simultaneously at serial time points using the Cardiac Array (Randox Laboratories Ltd, Crumlin, United Kingdom). RESULTS: Heart-type fatty acid-binding protein had the greatest sensitivity at 0 to 3 hours (64.3%) and 3 to 6 hours (85.3%) after chest pain onset. The combination of cTnI measurement with H- FABP increased sensitivity to 71.4% at 3 to 6 hours and 88.2% at 3 to 6 hours..RESULTS: Heart-type fatty acid-binding protein had the greatest sensitivity at 0 to 3 hours (64.3%) and 3 to 6 hours (85.3%) after chest pain onset. The combination of cTnI measurement with H- FABP increased sensitivity to 71.4% at 3 to 6 hours and 88.2% at 3 to 6 hours..

Receiver operating characteristic curves demonstrated that H- FABP had the greatest diagnostic ability with area under the curve at 0 to 3 hours of and 3 to 6 hours of The specificity was also high for the combination of H-FABP with cTnI at these time points. Heart-type fatty acid-binding protein had the highest negative predictive values of all the individual markers: 0 to 3 hours (93%) and 3 to 6 hours (97%). Again, the combined measurement of cTnI with H-FABP increased the negative predictive values to 94% at 0 to 3 hours, 98% at 3 to 6 hours, and 99% at 6 to 12 hours. CONCLUSION: Testing both H-FABP and cTnI using the Cardiac Array proved to be both a reliable diagnostic tool for the early diagnosis of myocardial infarction/acute coronary syndrome and also a valuable rule-out test for patients presenting at 3 to 6 hours after chest pain onset

Applying Research One size doesn’t fit all

Physicians searching skills are poor 23 Physicians answered multiple-choice questions and chose 2 to obtain further information using their own information resources.23 Physicians answered multiple-choice questions and chose 2 to obtain further information using their own information resources. For each questionFor each question –a mean of 13 minutes searching –an average of 1.8 resources Before searchingBefore searching –18 (39%) of the 46 answers were correct After searchingAfter searching –19 (42%) of the 46 answers were correct. 6 answers went from incorrect to correct; 5 went from correct to incorrect6 answers went from incorrect to correct; 5 went from correct to incorrect McKibbon KA, Fridsma DB. J Am Med Inform Assoc. 2006; 13(6):653-9.

Learning about “Just in Time” learning Keep a logbook of questionsKeep a logbook of questions Answer a few important questionsAnswer a few important questions Search and appraise yourself, thenSearch and appraise yourself, then Discuss with colleagues / mentorDiscuss with colleagues / mentor

“Journal” Clubs Learning about learning in teams (Post graduate “problem-based” learning) List our important current issues Vote on importance Search for evidence for next session Example Questions 1.Does ‘bibliotherapy’ help depression? 2.Should all diabetics take aspirin? 3.Are antidepressants safe in adolescents? 4.Is atenolol OK for hypertension? 5.What is the impact of Tamiflu on flu? 6.Is diabetic self-monitoring helpful?

Cased-Based Journal Clubs Case focusedCase focused Vote on topicsVote on topics Simple appraisalSimple appraisal Note further actionsNote further actions –More information –Equipment –Training –etc H

Questions?

The Prognosis of Ignorance is Poor

Implications for practice Interactive workshops can improve professional practice. Lectures alone are unlikely to change professional practice Treatment of Ignorance

Prevention & Treatment

If EBM looks impossible then resign it!

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JASPA* (Journal associated score of personal angst) J: Are you ambivalent about renewing your JOURNAL subscriptions? A: Do you feel ANGER towards prolific authors? S: Do you ever use journals to help you SLEEP? P: Are you surrounded by PILES of PERIODICALS? A: Do you feel ANXIOUS when journals arrive? * Modified from: BMJ 1995;311: (?liar) 1-3 (normal range) >3 (sick; at risk for polythenia gravis and related conditions)

Evidence alone is not enough Patients’ values Patients’ values Would you treat with antibiotics: Would you treat with antibiotics: a 75 YO patient who is, Demented, bedridden, contracted, debilitated, not oriented, who developed pneumonia ? a 75 YO patient who is, Demented, bedridden, contracted, debilitated, not oriented, who developed pneumonia ?

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